Documentation for Medical Records

Replaces Documentation for Acute Care, AB100704 The most respected resource for medical records documentation, Documentation for Medical Records is expertly revised and expanded for relevance to many healthcare settings. This book offers a practical orientation and overview of what health information management (HIM) and allied health students will encounter as they enter the healthcare profession. Content is organized for effective classroom use, meeting educator requirements and optimizing student learning. An insightful introduction to industry policies, procedures, and regulations that impact medical record documentation is also delivered. Key Features: Outlines basic healthcare documentation principles Addresses transition to electronic records Incorporates documentation for acute care as the practice model Covers documentation in ambulatory, home and hospice, behavioral, and long-term care settings Instructor guide available online CD with additional resources included About the Authors Barbara Odom-Wesley, PhD, RHIA, FAHIMA, is chair of the HIT Program at DeVry University, and is an HIM executive and consultant. Diann Brown, MS, RHIA, CHP, is an experienced HIM executive with a background in a variety of healthcare settings, and is a noted author and speaker on HIM topics. Chris L. Meyers, RHIA, is president of eCatalyst Consulting, a consulting firm specializing in the design and implementation of HER systems, eDiscovery and legal holds, and legal health records. She has extensive knowledge in implementing HER systems and is recognized nationally as a leader in HIM transformation.